Three-Year Survival after Transcatheter Aortic Valve Replacement: Findings from the Marshfield Aortic Valve Experience (MAVE) Study.

Background: Transcatheter aortic valve replacement (TAVR) is a rapidly evolving treatment for severe aortic stenosis. However, uncertainties exist for optimal valve selection as there are few long-term studies comparing patient survival by valve type.Objective: We hypothesized that self-expandable valves (SEV) would provide a survival advantage over balloon expandable valves (BEV), as SEV continue to expand and might better accommodate to the anatomy of the aortic valve over time.Methods: We examined outcomes according to valve type from a rural tertiary referral center between 2012 and 2017.Results: Out of 269 patients, 77 deaths (28.6%) occurred over the study period with 6 deaths by 1 month post-TAVR and 37 deaths by 1 year post-TAVR. The median observation time for survivors was 21.5 months. The probability of survival at 3 years was 60.7% and 61.9% for patients who underwent treatment with SEV and BEV, respectively. There was no statistically significant difference in overall patient survival with or without adjustment for factors such as age, sex, race, and aortic valve area. Additionally, in a secondary analysis restricted to those patients treated in later years (2015-2017) survival among patients with BEV appeared superior (HR=0.456, P=0.015).Conclusion: Patients who underwent TAVR at a rural medical center with SEV showed similar survival compared to those who received a BEV. Superior survival was observed among those who received BEV versus SEV between 2015 and 2017.

Multimodal Intervention Approach Reduces Catheter-associated Urinary Tract Infections in a Rural Tertiary Care Center.

OBJECTIVE: To compare the catheter-associated urinary tract infections (CAUTI) standardized infection rate (SIR) before and after implementation of a multimodal intervention approach in a rural tertiary hospital. DESIGN: Before-after analysis of a multimodal intervention to evaluate primary outcomes of the incidence of inpatient CAUTI, the SIR for CAUTI, and number of urinary catheter days. SETTING: All inpatient departments of a rural 504-bed tertiary care facility in the Midwest. PARTICIPANTS: Patients admitted for in-patient care. INTERVENTIONS: A multimodal intervention composed of: (a) physician and nurse education, (b) modification of progress note templates and daily provider reminders for the clinical necessity of catheters, (c) implementing established best practices for eliminating CAUTIs, (d) advocating for alternative toileting options, and (e) promoting aseptic techniques for insertion and removal of catheters. SIR, CAUTI, and the number of urinary catheter days were obtained before and after implementation of the multimodal intervention in 2015 and 2017, respectively. RESULTS: After a one-year timeframe of intervention, CAUTI event rates decreased, and SIR for CAUTI was reduced by 60.2% (from 1.524 to 0.607) with P value<0.05. Urinary catheter days were also reduced from 16,195 in 2015 to 13,348 in 2017 (17.6% reduction) with P value <0.05. CONCLUSIONS: Incidence of CAUTIs were significantly reduced with a team effort involving infection control, physician and nursing education, modification of progress note and templates and daily provider reminders for the clinical necessity of catheters and appropriate usage of urinary catheter with corresponding reduction in urinary catheter days.

Short-term metal particulate exposures decrease cardiac acceleration and deceleration capacities in welders: a repeated-measures panel study.

OBJECTIVE: Acceleration (AC) and deceleration (DC) capacities measure heart rate variability during speeding up and slowing down of the heart, respectively. We investigated associations between AC and DC with occupational short-term metal PM2.5 exposures. METHODS: A panel of 48 male welders had particulate matter less than 2.5 microns in diameter (PM2.5) exposure measurements over 4-6 h repeated over 5 sampling periods between January 2010 and June 2012. We simultaneously obtained continuous recordings of digital ECG using a Holter monitor. We analysed ECG data in the time domain to obtain hourly AC and DC. Linear mixed models were used to assess the associations between hourly PM2.5 exposure and each of hourly AC and DC, controlling for age, smoking status, active smoking, exposure to secondhand smoke, season/time of day when ECG reading was obtained and baseline AC or DC. We also ran lagged exposure response models for each successive hour up to 3 h after onset of exposure. RESULTS: Mean (SD) shift PM2.5 exposure during welding was 0.47 (0.43) mg/m(3). Significant exposure-response associations were found for AC and DC with increased PM2.5 exposure. In our adjusted models without any lag between exposure and response, a 1 mg/m(3) increase of PM2.5 was associated with a decrease of 1.46 (95% CI 1.00 to 1.92) ms in AC and a decrease of 1.00 (95% CI 0.53 to 1.46) ms in DC. The effect of PM2.5 on AC and DC was maximal immediately postexposure and lasted 1 h following exposure. CONCLUSIONS: There are short-term effects of metal particulates on AC and DC.

Initiation of Dialysis Is Associated With Impaired Cardiovascular Functional Capacity.

Background The transition to dialysis period carries a substantial increased cardiovascular risk in patients with chronic kidney disease. Despite this, alterations in cardiovascular functional capacity during this transition are largely unknown. The present study therefore sought to assess ventilatory exercise response measures in patients within 1 year of initiating dialysis. Methods and Results We conducted a cross-sectional study of 241 patients with chronic kidney disease stage 5 from the CAPER (Cardiopulmonary Exercise Testing in Renal Failure) study and from the intradialytic low-frequency electrical muscle stimulation pilot randomized controlled trial cohorts. Patients underwent cardiopulmonary exercise testing and echocardiography. Of the 241 patients (age, 48.9 [15.0] years; 154 [63.9%] men), 42 were predialytic (mean estimated glomerular filtration rate, 14 mL·min-1·1.73 m-2), 54 had a dialysis vintage ≤12 months, and 145 had a dialysis vintage >12 months. Dialysis vintage ≤12 months exhibited a significantly impaired cardiovascular functional capacity, as assessed by oxygen uptake at peak exercise (18.7 [5.8] mL·min-1·kg-1) compared with predialysis (22.7 [5.2] mL·min-1·kg-1; P<0.001). Dialysis vintage ≤12 months also exhibited reduced peak workload, impaired peak heart rate, reduced circulatory power, and increased left ventricular mass index (P<0.05 for all) compared with predialysis. After excluding those with prior kidney transplant, dialysis vintage >12 months exhibited a lower oxygen uptake at peak exercise (17.0 [4.9] mL·min-1·kg-1) compared with dialysis vintage ≤12 months (18.9 [5.9] mL·min-1·kg-1; P=0.033). Conclusions Initiating dialysis is associated with a significant impairment in oxygen uptake at peak exercise and overall decrements in ventilatory and hemodynamic exercise responses that predispose patients to functional dependence. The magnitude of these changes is comparable to the differences between low-risk New York Heart Association class I and higher-risk New York Heart Association class II to IV heart failure.

Associations between trunk flexion and physical activity of patient care workers for a single shift: A pilot study.

BACKGROUND: Trunk flexion and occupational physical activity are parameters that have been used to assess and characterize jobs with high physical demands. OBJECTIVE: Characterize the physical load of trunk flexion and physical activity of patient care unit (PCU) workers during a single work shift. METHODS: Participants wore an accelerometer to measure physical activity and an inclinometer to assess trunk flexion during a single work shift, which was compared using correlation and linear regression analyses. RESULTS: Participants spent 74% of their work time upright between - 10° to 20° and 19% of their time flexed between 20° to 45°. On average workers spent 3% and 5% of their time, in the extreme postures of less than - 10° and greater than 45°, respectively. Participants spent 99% of their shift below moderate and vigorous activity. The largest correlation found was between the number of forward trunk flexions to 20° degrees per shift and minutes in lifestyle activity (r = 0.6, p < 0.001). No correlations between minutes of moderate or vigorous physical activity and trunk flexion were observed. CONCLUSIONS: This study suggests that the physical demands of patient care unit workers as measured through trunk flexion are associated with lifestyle and light levels of physical activity.

An epigenome-wide association analysis of cardiac autonomic responses among a population of welders.

DNA methylation is one of the potential epigenetic mechanisms associated with various adverse cardiovascular effects; however, its association with cardiac autonomic dysfunction, in particular, is unknown. In the current study, we aimed to identify epigenetic variants associated with alterations in cardiac autonomic responses. Cardiac autonomic responses were measured with two novel markers: acceleration capacity (AC) and deceleration capacity (DC). We examined DNA methylation levels at more than 472,506 CpG probes through the Illumina Infinium HumanMethylation450 BeadChip assay. We conducted separate linear mixed models to examine associations of DNA methylation levels at each CpG with AC and DC. One CpG (cg26829071) located in the GPR133 gene was negatively associated with DC values after multiple testing corrections through false discovery rate. Our study suggests the potential functional importance of methylation in cardiac autonomic responses. Findings from the current study need to be replicated in future studies in a larger population.

Long-Term Metal PM2.5 Exposures Decrease Cardiac Acceleration and Deceleration Capacities in Welders.

OBJECTIVE: The aim of the study was to clarify whether long-term metal particulates affect cardiac acceleration capacity (AC), deceleration capacity (DC), or both. METHODS: We calculated chronic exposure index (CEI) for PM2.5 over the work life of 50 boilermakers and obtained their resting AC and DC. Linear regression was used to assess the associations between CEI PM2.5 exposure and each of AC and DC, controlling for age, acute effects of welding exposure, and diurnal variation. RESULTS: Mean (standard deviation) CEI for PM2.5 exposure was 1.6 (2.4) mg/m-work years and ranged from 0.001 to 14.6 mg/m-work years. In our fully adjusted models, a 1 mg/m-work year increase in CEI for PM2.5 was associated with a decrease of 1.03 (95% confidence interval: 0.10, 1.96) ms resting AC, and a decrease of 0.67 (95% confidence interval: -0.14, 1.49) ms resting DC. CONCLUSIONS: Long-term metal particulate exposures decrease cardiac accelerations and decelerations.

Are the Associations of Cardiac Acceleration and Deceleration Capacities With Fine Metal Particulate in Welders Mediated by Inflammation?

OBJECTIVE: The aim of this study was to investigate whether associations of acceleration capacity (AC) and deceleration capacity (DC) with metal-PM2.5 are mediated by inflammation. METHODS: We obtained PM2.5, C-reactive protein, interleukin (IL)-6, 8, and 10, and electrocardiograms to compute AC and DC, from 45 male welders. Mediation analyses were performed using linear mixed models to assess associations between PM2.5 exposure, inflammatory mediator, and AC or DC, controlling for covariates. RESULTS: The proportion of total effect of PM2.5 on AC or DC (indirect effect) mediated through IL-6 on AC was 4% at most. Controlling for IL-6 (direct effect), a 1 mg/m increase of PM2.5 was associated with a decrease of 2.16 (95% confidence interval -0.36 to 4.69) msec in AC and a decrease of 2.51 (95% confidence interval -0.90 to 5.93) msec in DC. CONCLUSION: IL-6 may be mediating the effect of metal particulates on AC.

Physical activity levels at work and outside of work among commercial construction workers.

OBJECTIVE: Characterize the number of minutes of moderate and vigorous physical activities at work and outside of work during seven consecutive days, in a sample of 55 commercial construction workers. METHODS: Workers wore accelerometers during work and outside-of-work hours for seven consecutive days and completed brief survey at the seventh day of data collection. RESULTS: From the directly measured physical activity, the average number per participant of moderate minutes of occupational physical activity and physical activity outside of work obtained in short bouts were 243 minutes (65%) and 130 minutes (35%), respectively. Directly measured minutes of vigorous occupational physical activity were significant and positively correlated with self-reported fatigue. CONCLUSIONS: Among commercial construction workers, physical activity from work contributes significantly, approximately two thirds, toward a worker's total amount of weekly minutes of moderate physical activity.

Physical activity at work contributes little to patient care workers' weekly totals.

OBJECTIVE: To determine the number of minutes of moderate and vigorous physical activity at work in comparison to weekly total minutes in a pilot study of 50 hospital patient care workers. METHODS: Workers wore accelerometers during work and nonwork hours for 7 days, and completed surveys at the end of the seventh day. RESULTS: Although the participants reported on average 206 minutes of moderate activity at work, the accelerometers recorded on average 30 minutes of moderate activity at work. For the 7 days the accelerometers measured a total of 165 minutes of moderate activity. Self-reported fatigue and functional limitations were negatively correlated albeit weakly with measured minutes of vigorous activity outside of work. CONCLUSIONS: Physical activity at work on patient care units contributes a small fraction to these workers' weekly totals, and in turn meeting guidelines.